Consideration of the Temporal Relationship Between Surgery and Radiation Therapy

Patients with an impending or realized pathologic fracture from metastatic bone disease often benefit from surgical intervention in combination with radiation therapy. Although this bimodality therapy improves patient outcomes and implant survival, the addition of radiotherapy has the potential to increase the risk for postoperative complications. Wound healing, an organized active biologic process, is highly susceptible to the detrimental effects of ionizing radiation as a function of dosage. Neovascularization, collagen synthesis, and remodeling are most affected, resulting in a decreased rate of wound healing and wound tensile strength following exposure to larger doses of radiation therapy. A diverse array of basic science and clinical studies demonstrate that wound healing complications can be minimized by limiting the dose of radiation and adjusting the time interval between the two procedures. Wound healing mechanisms are most sensitive to the detrimental effects of ionizing radiation during the first 48 h postoperatively. Therefore, when large doses are planned, administration of radiation should be avoided during this period. It should be pointed out however that the doses of radiation employed in the setting of metastatic bone disease are far less than for those to control a primary sarcoma. Managing oncology patients requires multidisciplinary treatment. Orthopedic surgeons and radiation oncologists provide complementary skill sets, and communication between the two service lines is critical to minimize metastatic bone disease-related morbidity. This chapter is, in part, a plea to initiate and grow that relationship for the benefit of our patients.